﻿@section TitleContent {
	Make a Payment
}

				<div class="contentRegion">
					<div class="contentRegionFull">
						<div class="contentRegionHeader">Make a payment</div>
						<div class="contentRegionContainer">
							<form action="Payment" method="post">
								<p>
									<label for="FirstName">First Name</label>
									<input type="text" id="FirstName" name="FirstName" value="" />
								</p>
								<p>
									<label for="LastName">Last Name</label>
									<input type="text" id="LastName" name="LastName" value="" />
								</p>
								<p>
									<label for="CCV">CC Number</label>
									<input type="text" id="CC" name="CC" value="" />
								</p>
								<p>
									<label for="ExpDate">Expiration Date</label>
									<input type="text" id="ExpDate" name="ExpDate" value="" />
								</p>
								<p>
									<label for="CCV">CCV Number</label>
									<input type="text" id="CCV" name="CCV" value="" />
								</p>
								<p>
									<label for="NameOnCard">Name on Card</label>
									<input type="text" id="NameOnCard" name="NameOnCard" value="" />
								</p>
								<p>
									<input type="button" id="Cancel" name="Cancel" value="Cancel" />
									<input type="submit" id="Submit" name="Submit" value="Submit" />
								</p>
							</form>
						</div>
					</div>
				</div>